=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104246362
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATTS HEALTHCARE CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2014
-----------------------------------------------------
Last Update Date | 05/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 316 E 111TH ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90061-3004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-568-3093
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10300 COMPTON AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90002-3628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-357-6680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT CONTROLLER
-----------------------------------------------------
Name | DAVID BRUMLAGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-564-4331
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number | 550002583
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------